title: Facilitators and barriers in pain management for trauma patients in the chain of emergency care.
abstract: BACKGROUND
  The aim of the study is to give insight into facilitators and barriers in pain management in trauma patients in the chain of emergency care in the Netherlands.
  
  
  METHODS
  A qualitative approach was adopted with the use of the implementation Model of Change of Clinical Practice. The chain of emergency care concerned prehospital Emergency Medical Services (EMS) and Emergency Departments (EDs). We included two EMS ambulance services and three EDs and conducted five focus groups and 10 individual interviews. Stakeholders and managers of organisations were interviewed individually. Focus group participants were selected based on availability and general characteristics. Transcripts of the audio recordings and field notes were analysed in consecutive steps, based on thematic content analysis. Each step was independently performed by the researchers, and was discussed afterwards. We analysed differences and similarities supported by software for qualitative analysis MaxQDA.
  
  
  RESULTS
  This study identified five concepts as facilitators and barriers in pain management for trauma patients in the chain of emergency care. We described the concepts of knowledge, attitude, professional communication, organisational aspects and patient input, illustrated with quotes from the interviews and focus group sessions. Furthermore, we identified whether the themes occurred in the chain of care. Knowledge deficits, attitude problems and patient input were similar for the EMS and ED settings, despite the different positions, backgrounds and educational levels of respondents. In the chain of care a lack of professional communication and organisational feedback occurred as new themes, and were specifically related to the organisational structure of the prehospital EMS and EDs.
  
  
  CONCLUSIONS
  Identified organisational aspects stressed the importance of organisational embedding of improvement of pain management. However, change of clinical practice requires a comprehensive approach focused at all five concepts. We think a shift in attitudes is needed, together with constant surveillance and feedback to emergency care providers. Implementation efforts need to be aimed at the identified barriers and facilitators, tailored to the chain of emergency care and the multi-professional group of emergency care providers.
authors.affiliation: Emergency Department and Regional Emergency Healthcare Network, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. S.Berben@azo.umcn.nl
authors.forename: Sivera A A
authors.initials: SA
authors.lastname: Berben
authors.forename: Tineke H J M
authors.initials: TH
authors.lastname: Meijs
authors.forename: Pierre M
authors.initials: PM
authors.lastname: van Grunsven
authors.forename: Lisette
authors.initials: L
authors.lastname: Schoonhoven
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
mesh_terms: D001291:Attitude of Health Personnel; D003142:Communication; D004632:Emergency Medical Services / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D017144:Focus Groups; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008962:Models, Theoretical; D009426:Netherlands / Q000453:epidemiology; D059408:Pain Management / Q000379:methods*; D010348:Patient Care Team; D036301:Qualitative Research; D011795:Surveys and Questionnaires; D014947:Wounds and Injuries / Q000188:drug therapy* / Q000453:epidemiology